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Coming Back to Life … Let’s Break the Silence!

“For millions of years mankind lived just like the animals
Then something happened which unleashed the power of our imagination
We learned to talk”
— Pink Floyd, Keep Talking

“Lost in thought and lost in time
While the seeds of life and the seeds of change were planted
Outside the rain fell dark and slow
While I pondered on this dangerous but irresistible pastime
I took a heavenly ride through our silence
I knew the moment had arrived
For killing the past and coming back to life”
— Pink Floyd, Coming Back to Life

This will not be another article on wellness, but rather about the reality of the effects of lack of wellness. This article is about depression and suicide as the end of the road. This is my personal point-of-view and is not research based. In the past eight months, tragedy has struck all around me. On August 18, 2017, one of my attendings, who was never late to a shift, was found dead by me when he did not show up to work. It was discovered that his death at age 55 was related to his chronic alcoholism. On November 20th, a friend, mentor, and leader in EM education was murdered in his home at age 62. On April 20th, a dear friend and world famous musician took his own life at age 28. On May 25th, an acquaintance working in the nightlife/hospitality took his own life at age 55. Why? How? But most important, could any of these have been prevented? Could I have done anything more?

Much of what is written on burnout has been about recognizing and preventing it, but there is very little discussion about what to do when we are unwell. We define “burnout” as a state of emotional, mental, and physical exhaustion caused by prolonged stress. We all know the affect it can have on our body, psychology, work, and personal relationships. We are told what we need to do: drink less, exercise more, spend more time with our family, do yoga, get adequate sleep, be thankful for what we have, etc. Physicians are goal oriented, over-achievers. If we are given a list of ways to improve and be well, we often feel as though we failed at taking advantage of an “easy solution” and that it is our fault for being unwell. We feel as though we are broken, rather than the system is breaking us.

Physician suicides have been increasing over the past century and even more alarming — suicide is the second cause of death among medical students. The numbers are reported to be 300-400 per year, but this is often under reported. In my early years, I could not understand suicide. I saw it as a sign of weakness. Then, I served in the Air Force during Desert Storm and Desert Shield and something happened when I got home and separated from the service that I could not understand, could not explain and most importantly, could not face or admit that it was happening to me. I had lost the joy of life. I had survivors’ guilt, but I wasn’t aware or did not want to deal with it. At a skydiving event, my older brother came to see me, and jokingly I made the comment “God does not want me, if he wanted me, he would have taken my life already.” That day, I broke the safety limits off while opening my parachute for fun, and later had a major malfunction. If my safety device had not opened my reserve, I would not be here today to write this. My brother was petrified and looked at me and told me “Bro, I love you, please stop this shit, we all love you, please.”

Like most emergency physicians, we are great at dealing with stress. We pride ourselves that we can multi-task, but what we really do is put our issues in boxes and tuck them away in our subconscious and forget about them — out of sight out of harm. I was great at this — put it away and do not address anything and press on. On the night before 09/11/2001, I was working the overnight shift at Maimonides Medical Center. The next morning, we received a report at 8:48am that “a plane had crashed into the World Trade Center.” I jumped at the opportunity to skip out on computer training and respond to the disaster ... the rest is history. Still, I would not talk about the horrific events that happened that day and placed everything in yet another box. Exactly one year later at residency conference, my program director, had one minute of silence at 9am and at that exact moment, I became paralyzed and in tears. Why not me, why am I alive? My program director brought me down to her office to “Much of what is written on burnout has been about recognizing and preventing it, but there is very little discussion about what to do when we are unwell.” talk, and told me I needed help. She sent me to our ACGME office, where they listened to me ramble for an hour and from there, we went to a psychologist trained in PTSD and survivor’s guilt. After, a few sessions and group therapy, I realized that I was not the only one, others felt exactly like me. I was not crazy or abnormal. My journey to acknowledge the stressor and what I needed to do was a long painful one. But after several years, I know how to cope with it and I thank GOD for sparing my life because of all the patients I had the opportunity to save, and make a difference in their lives, who might not have survived without me.

But, we all have something in common … the stigma of being labeled, the fear of being seen differently, the fear of losing our job. As physicians, we have been competing against each other for years, we criticize each other, we work countless hours with each other without really knowing each other. Then something happens and we all ask each other “How did we miss it?” When my attending died that I worked closely with for years, I questioned myself for weeks. How did I miss it? Were there any red flags? He was a model employee, always early for his shift, smiling and joking, and not showing signs that would raise any concerns. No one really knew him outside work; we only knew what he wanted us to know. In retrospect, work was his sanctuary — his happy place. But looking back, no one questioned why he wasn’t at the last three holiday parties, our residents’ graduation night, or any wellness event.

There are common themes among those suffering burnout and depression. Some of the first themes are: to withdraw, consume an excess of alcohol, not want to be involved, not care anymore. But the worst is the feeling that you have no one to talk to or that you cannot because you feel isolated, you feel that you are going crazy. During my stress reaction, I would hear a lot of people telling me what I needed to do, but no one really wanted to hear what I had to say and the voices in my head were telling me “They don’t understand,” “this is useless.” So, when someone asks you, “Hey, can we go have a drink, I need to talk,” please take a moment from your busy schedule and say, “Yes.” And, if the person starts opening Pandora’s box, let them know that it is safe for them to share and let them speak. Listen to them, don’t offer your opinion unless it is asked for. Reassure them that they are not the only one, that what they are feeling is normal, and help is available. Many people can be talked off the edge just by listening. Next, get a small group of colleagues and friends together and formulate a plan. Make a point to get that person involved, even if it means driving to their house to check on them. Let them know it is safe for them to call you when the “darkness overcomes the light.”

Finally, and most importantly let us de-stigmatize depression as something that happens to others, have regular discussions about it, learn the signs, educate yourself and your colleagues. Let’s treat each other with respect and create plans within our institutions with a “safe talk” environment where one can express their feelings without fear of consequence. If a life-changing event happens, get involved and check on each other. Let’s break down the barriers and recognize we all at one point in our life will contemplate suicide, and let’s look out for each other. We learned to talk, but let’s learn to listen.